RCHC Sharing Promising Practices: Santa Rosa Community Health CDSS for Tobacco Screening and Follow-up Documentation

Transcription

1 RCHC Sharing Promising Practices: Santa Rosa Community Health CDSS for Tobacco Screening and Follow-up Documentation Categories: Clinical Practice Operations Compliance Finance Aim: To improve tobacco screening and follow-up documentation for Santa Rosa Community Health (SRCH) patients. Target Population: All adults ages 18 and over. Promising Practice Overview: SRCH s tobacco screening and follow-up for PHASE program reporting (UDS definition) was 51% in 2015 Q3 and increased to 75% as of 2017 Q2. This improvement was a direct result of EHR optimizations and implementing CDSS alerts in ecw. SRCH s Interventions Workgroup decided in mid-2016 to standardize documentation to preventive medicine and removed documentation locations in HPI and social history. SRCH invested in building out their preventive medicine section so tobacco screening and follow-up documentation was visible, they deleted all other locations and provided training for staff in January In just a couple of quarters after implementation of CDSS, SRCH s tobacco screening and cessation counseling improved by 15%. Measures: Tobacco Use Assessment and Cessation Intervention (UDS Definition) Numerator: Patients who had a tobacco assessment within two years prior to their last medical visit If the patient was a tobacco user in the past two years, the patient had at least one of the following within two years prior to their last medical visit: o Tobacco use cessation counseling o Smoking cessation agents (active medication or order) Denominator: 18 years of age or older during the reporting period and seen after their 18th birthday Had at least two medical visits or at least one preventive visit during the reporting period Last updated 9/29/17

2 Pre-existing infrastructure: Prior to 2016, SRCH did not utilize CDSS alerts and clinical staff were documenting tobacco screening and counseling in up to 15 different places in the EHR. Upon chart audits for RCCO, QI staff noticed many tobacco screenings occurred that were never documented or captured properly. Changes: SRCH hired a consultant through HITCare who built out the preventive medicine section in their EHR to make the tobacco screening and follow-up documentation more visible. The consultant deleted other areas - aside from preventive medicine - where staff documented tobacco screening and counseling along with other UDS measures such as cervical cancer screenings. SRCH trained all of their clinical staff to document in the preventive medicine location in January Along with the trainings, QI staff updated and rolled out CDSS alerts in March 2017 starting with tobacco screenings and cervical cancer screenings. CDSS now alerts clinical staff if a patient is overdue on certain preventive screenings by displaying in red. SRCH s QI and EHR teams were working so closely that SRCH decided to develop a special team named the EHR Optimization Team and hired a designated trainer to train new clinical staff. In April 2016, the EHR Optimization Team updated their medication groups to more accurately reflect the combo medications that are used more in non-primary care visits such as behavioral health visits. As staff started to screen more frequently and encountered patients with the desire to quit smoking, clinical staff are using MI techniques to set action plans and providing those patients with encouragement cards to stop smoking. SRCH uses BUTTS resources. Results: SRCHC s measure for tobacco screening and follow-up documented improved to 75% in June 2017 as a direct result of these activities. While tobacco screenings and counseling were being completed prior to 2017, they were not always documented in the proper locations and not captured in the reporting. The improved preventive medicine section of their EHR (ecw) and deletion of all other locations where staff was documenting tobacco screening and follow-up combined with staff training and new CDSS alerts facilitated improved systems and outcomes for this measure. The creation of a new EHR Optimization Team at SRCH is making these improvements sustainable through ongoing trainings and expertise to continue optimizations and CDSS maintenance. Conclusions: Last Updated: 9/29/17

3 Proper documentation alone can improve performance on screening measures such as tobacco screenings and follow-up documentation. Documentation can be improved through EHR optimizations such as cleaning up EHR documentation locations to only allow clinic staff to document in one single location, which is the same location mapped to the reports. Additionally, implementing CDSS alerts to ensure patients receive screenings when due and staff engage in conversations about tobacco cessation when appropriate can make a difference in improving tobacco cessation efforts. Companion Documents: MA Rooming Clinical Alerts Last Updated: 9/29/17

4 SBIRT Process Screening, Brief Intervention, and Referral to Treatment MA rooms patient; Alcohol screening is needed MA screens for Alcohol Use using AUDIT-C Smart Form FEMALES: The point total is 0, 1, or 2: Interpretation of screening is Negative The point total is 3 or more: Interpretation of screening is Positive MA Deploys MA: AUDIT C NEGATIVE template NEGATIVE MA notes Interpretation MALES: The point total is 0, 1, 2, or 3: Interpretation of screening is Negative The point total is 4 or more: Interpretation of screening is Positive POSITIVE MA picks up document from printer and placed it in slot on door, as usual MA completes with intake MA Deploys MA: AUDIT C POSITIVE template MA prints education material from Order Set and gives materials to patient. MA hands patient laminated copy of Alcohol Use and Your Health, saying to patient: Here is some information you can look over while you are waiting for your clinician. If patient declines, document in Preventive Medicine Diagnosis, such as: - Alcohol abuse - Binge drinking - Alcohol dependence - Polysubstance abuse MA completes intake Referral to Treatment, such as: - Motivational Interviewing discussion (chart in Notes section of Progress Note) - BH Warm handoff - Print list of AA meetings (from Order Set) - Print brochure of local treatment programs (from Order Set) - SRCHC group brochure (from Order Set) Use Order Set/Procedure to document Use Referral to document, as needed As needed, Clinician: Diagnoses and Refers to Treatment using Order Set Proceed with visit.

5 CDSS Patient is due for Colon CA screen Has patient had FIT in last year or Colonoscopy done in last 10 years? Colorectal Cancer Screening OPPORTUNITY!! Briefly explain to patient importance and how easy FIT is to do. Document in Preventive Medicine Select: Declined in today s visit OR Requested recent results Does pt commit to completing FIT? Does patient have Medicare? Use CDSS to order FIT (Medicare) Use CDSS to order the FIT Give patient FIT card. Other intervention strategies being discussed: TWO weeks before the patient s visit. Outreach contact, confirms, informs, sends kit. Patient brings it to their appt, happy that they provided a specimen!

6 CDSS Review CDSS tab on Right Chart Panel Tobacco Assessment/ Intervention Smoking assessment should be done annually per CDSS guidelines Is Smoking Assessment due? Use Tobacco Control Smart Form to document Smoking Status and save data Is Patient a Current Smoker? Provide educational materials as appropriate MA goes to Preventive medicine, Counseling, Smoking patient visit. Click in Notes field, complete top two values Options

7 CDSS Breast Cancer Screening Review CDSS tab on Right Chart Panel Breast Cancer Screening should be performed every months on female patients 50 yrs and older per guidelines CDSS is set at 18 months. Is Breast CA screen due? Request records Scan ROI and assign to HIM Has patient had mammo elsewhere in last 12 months? Document requested recent results, see ROI for more detail in preventive medicine under Declined screening test offered Document Test declined in preventive medicine under Declined screening test offered Does pt commit to getting mammo done? Order per Protocol Under Breast Cancer Screening Order the Mammo Right Chart Panel: --Click on the plus, then the arrow by Breast CA Screen. --Check the box to select the Linked Assessment: Z And click OK. Congratulations! You have ordered the Mammo!

8 Cervical Cancer Screening Patient is due for Cervical CA screening CDSS Alert Inform patient they are due. We re glad you re here today. To save a trip back for your cervical cancer screening, we re going to set up your Pap today. Tell patient we re going to do it today THESE are the CURRENT PAP Templates. Patient agrees, cheerfully Provide good reasons for early cancer detection. VERIFY insurance and merge proper template Patient reconsiders & demands Pap Still Declines Kudos for helping to save lives! Document declination in Preventive Medicine

9 Hepatitis C Virus Screening CDSS Patient is due for Hepatitis C screening The US Preventive Services Task Force recommends a 1-time screening for HCV infection to adults born between 1945 and Explain importance of Hep C Screening to patient Patient agrees to screening Document in Preventive Medicine Merge Template: Hepatitis C Screening (All Baby Boomers)

10 Lead testing (ages 1 & 2) CDSS Has child had Lead completed and in ecw within the last 11 months Does parent/guardian consent for testing? MA notifies provider that parent/guardian refuses testing MA uses CDSS to order Lead blood test MA transmit Lead order to Quest and hands parent/guardian a copy of the order MA continues with patient visit